Wrist/Hand
Leg/Knee/hip
Leg/knee cont.
Back/shoulder
Misc
100
A 29-year-old male presents to your office because of pain and paresthesia in his right fourth and fifth fingers for the last several weeks. He has had some generalized weakness in his hands, noting that it is more difficult for him to grasp and pick up small objects with his thumb and forefinger. There is no history of trauma. He is very physically active and lifts weights 5–6 days per week. On physical examination you note weakness of the pincer mechanism and decreased sensation over the hypothenar eminence and fourth and fifth fingers.
These findings are associated with peripheral entrapment of which one of the following nerves?
A) Axillary
B) Median
C) Radial
D) Suprascapular
E) Ulnar
E) Ulnar: commonly caused by activities that place pressure on the volar aspect of the wrist, including weightlifting and cycling
Axillary: results from shoulder dislocations, humeral neck fracture, and pressure from crutch use. Presents with decreased sensation or pain over the lateral shoulder and weakness with shoulder external rotation, abduction, and extension.
Median: paresthesia of the first three fingers resulting in thenar muscle atrophy.
Radial: most commonly compressed by sustained pressure over the radial groove. Presents with paresthesia/pain in the posterior forearm and dorsal hand, weakness in wrist and finger extensors (wrist drop).
Suprascapular: can present similarly to axillary nerve entrapment, with shoulder pain and abduction and forward flexion deficits.
100
A 34-year-old male presents with a 2-week history of right plantar heel pain that began after he started training for a marathon. The pain is most severe immediately upon standing in the morning and then gradually improves somewhat after ambulation. It worsens again if he stands after sitting for a period of time or after excessive walking or running.
Which one of the following is supported by evidence as a first-line intervention to provide pain relief for this condition?
A) Night splints
B) Plantar fascia stretching exercises
C) Acupuncture
D) Extracorporeal shock wave therapy
E) Platelet-rich plasma injection
B) Plantar fascia stretching exercises
Study results regarding pain relief with the use of night splints is conflicting and inconclusive.
Acupuncture: studies available are of low quality.
Extracorporeal shock wave therapy is only recommended after conservative therapies fail and for chronic plantar fasciitis.
Platelet-rich plasma injections may be indicated in refractory plantar fasciitis but are not considered first-line therapy for an acute presentation.
100
A 40-year-old runner presents with pain in the left leg. He is training for a marathon and has been increasing his running distance in recent weeks. He reports localized pain and swelling at the midpoint of the shin over the past 4 weeks that begins after a run and lasts for a few days, but now the swelling and tenderness have lasted for several days and there is severe pain when he tries to run. You suspect a tibial stress fracture.
Which one of the following imaging modalities would be indicated initially?
A) A plain film
B) Ultrasonography
C) CT
D) MRI
E) Bone scintigraphy
A) A plain film
For a suspected tibial stress fracture, plain radiography is indicated as the initial imaging modality
If plain radiography is normal and further imaging is warranted, MRI or bone scintigraphy should be considered.
100
A 62-year-old male was recently diagnosed with adhesive capsulitis. Which one of the following is associated with a higher risk of developing adhesive capsulitis compared with the general population?
A) Addison’s disease
B) Diabetes mellitus
C) Hyperparathyroidism
D) Hypertension
E) Rheumatoid arthritis
B) Diabetes mellitus
Prevalence of diabetes in patients with adhesive capsulitis is about 30%
Screening for diabetes with a fasting glucose level or hemoglobin A1c is recommended in patients with adhesive capsulitis who have not previously been diagnosed with diabetes.
100
A 67-year-old female patient began taking a bisphosphonate for treatment of osteoporosis 2 years ago after a DXA scan revealed a T-score of –2.7. Her FRAX score showed a 10-year probability of hip fracture of 5%. You order a repeat DXA scan and her T-score is now –2.3 and her FRAX score is 3.5%.
Which one of the following should you recommend to this patient regarding the duration of treatment with a bisphosphonate?
A) Stop taking it now
B) Continue taking it for 1 more year
C) Continue taking it for 3 more years
D) Continue taking it for 7 more years
E) Continue taking it indefinitely
C) Continue taking it for 3 more years
Treatment is indicated for patients with a T-score of –2.5 or less, or osteopenia, defined as a T-score of –1 to –2.5 and a 10-year probability of hip fracture of at least 3% using the FRAX tool.
Treatment beyond 5 years in women who do not have a persistent T-score of –2.5 or less has not been shown to result in further decreases in rates of clinical vertebral fractures, nonvertebral fractures, or mortality (SOR C). In addition, there is increasing evidence that the risk of atypical fracture of the femur increases with the use of bisphosphonates beyond 5 years.
200
An otherwise healthy 37-year-old female presents to your office with elbow pain 1 day after falling while skiing. She has pain and tenderness along the lateral aspect of the affected elbow and limited range of motion of the elbow and forearm. Radiographs confirm a nondisplaced fracture of the radial head.
Which one of the following would be most likely to produce satisfactory outcomes?
A) Immobilization for 3 days followed by range-of-motion exercises
B) A long arm posterior splint for 6 weeks
C) A long arm cast for 6 weeks
D) Referral to an orthopedist for cast placement
E) Referral to an orthopedist for surgical repair
A) Immobilization for 3 days followed by range-of-motion exercises
Immobilization for 6 weeks using either a long arm posterior splint or a long arm cast is not necessary. More advanced or displaced fractures may require a referral to an orthopedist for cast placement or operative repair, but nondisplaced radial head fractures can be managed by primary care physicians.
200
55-year-old female presents for a telehealth visit because of a 2-month history of right lateral hip pain. Her symptoms began shortly after she started jogging. The pain worsened a week ago after a long car trip. She reports that the pain has been interfering with her sleep quality, particularly if she rests on her right side. You ask her to walk away from her video camera so you can observe her ambulation. You note a Trendelenburg gait with her body shifting to the right side.
Which one of the following is the most likely diagnosis?
A) Femoroacetabular impingement
B) Greater trochanteric pain syndrome
C) A hamstring strain
D) A labral tear
E) Sacroiliac joint dysfunction
B) Greater trochanteric pain syndrome
Can also include bursitis as well as gluteus medius tendinopathy or tears. Trendelenburg gait, which indicates gluteus muscle weakness.
Both femoroacetabular impingement and labral tears generally cause anterior hip pain. FAI is usually caused by a cam deformity and/or a pincer deformity of the hip joint
Labral tears are usually associated with a history of trauma or sports-related injury.
Hamstring injuries and sacroiliac joint dysfunction generally cause posterior hip pain.
200
A 13-year-old male presents with a 3-week history of pain in the anterior right knee that is worse when descending stairs and jumping. He is active in sports but has no recent history of injury. On examination you note tenderness and swelling over the tibial tuberosity, but no redness or warmth.
Which one of the following would be most appropriate before initiating treatment?
A) No imaging
B) Plain film radiographs
C) Ultrasonography
D) MRI
E) A bone scan
A) No imaging
Patient has Osgood-Schlatter based on history and exam. Imaging is not needed.
If symptoms persist/worsen, then plain film is next best step.
200
A 26-year-old recreational baseball player presents with recurrent right shoulder pain that tends to gradually worsen during play and is relieved by rest. His other daily activities have not been affected and he has no nighttime pain.
Examination of the right shoulder reveals a normal appearance, no tenderness to palpation, normal abduction strength, and a positive painful arc at 90°. The drop-arm rotator cuff test is negative, the Hawkins impingement sign is mildly positive, the empty-can supraspinatus test is moderately positive, and the Gerber liftoff test is negative. Radiographs of the right shoulder are normal.
Which one of the following would be appropriate at this time to provide long-term pain relief?
A) Complete shoulder rest with temporary use of a shoulder sling
B) Recommending that he permanently stop playing baseball
C) A subacromial corticosteroid injection
D) Physical therapy
E) Referral for arthroscopic surgery
D) Physical therapy
Patient has shoulder impingement syndrome (positive Hawkins impingement sign) and evidence of supraspinatus tendinopathy (with a positive empty-can rotator cuff test).
However, the negative drop-arm test is evidence against a complete rotator cuff tear. Absence of night pain supports this. Physical therapy, along with pain control using NSAIDs, acetaminophen, or short-term opiate medication, would be most appropriate as initial therapy.
Complete shoulder rest is inappropriate since his daily activities are not aggravating the problem. A subacromial corticosteroid injection, while commonly done and likely to provide short-term pain relief, is unlikely to provide long-term improvement in pain and function.
200
A 35-year-old female with rheumatoid arthritis currently being treated with adalimumab (Humira) injections sees you for evaluation after developing a red, swollen, warm, and painful right knee. Arthrocentesis is performed, and the synovial fluid analysis is concerning for septic arthritis.
Which one of the following organisms is the most likely cause of her infection?
A) Candida albicans
B) Escherichia coli
C) Mycobacterium tuberculosis
D) Staphylococcus aureus
E) Streptococcus pyogenes
D) Staphylococcus aureus
Patients with rheumatoid arthritis being treated with anti-tumor necrosis factor therapy are at increased risk for septic arthritis. The most common cause of septic arthritis in adults is Staphylococcus aureus, followed by Streptococcus species.
300
A 43-year-old male sees you because of popping and clicking at the base of his index finger. On examination you note a nodule on the palmar aspect of the metacarpophalangeal joint with the finger flexed.
Which one of the following is the most likely diagnosis?
A) Calcific peritendinitis
B) Dupuytren contracture
C) Flexor tenosynovitis
D) Rheumatoid arthritis
E) Trigger finger
E) Trigger finger
Can be associated with diabetes mellitus.
300
A 62-year-old female underwent a total knee replacement 3 months ago. She has no other surgical history and is in good health. Her dental office calls you to discuss antibiotic prophylaxis prior to a dental cleaning.
Based on current guidelines, which one of the following would be most appropriate regarding antibiotic prophylaxis prior to routine dental procedures in this patient?
A) No prophylaxis
B) Prophylaxis for 6 months post knee replacement
C) Prophylaxis for 1 year post knee replacement
D) Prophylaxis for 5 years post knee replacement
E) Prophylaxis for the patient’s lifetime
A) No prophylaxis
Current evidence to support antibiotic prophylaxis is limited and antibiotic use is known to increase cost, bacterial resistance, and the risk of adverse drug reactions.
300
An obese 60-year-old male presents with knee pain after a fall. He reports that 2 days ago he slipped on some ice and fell forcefully onto his left knee. He is able to walk but does have a noticeable limp. On examination he is able to flex his knee past 90° and has no point tenderness.
Which one of the following would be most appropriate at this time?
A) Anti-inflammatory medication
B) A corticosteroid injection
C) A knee brace
D) A radiograph
E) MRI
D) A radiograph
Ottawa knee rule: repeatedly validated with a sensitivity of 98.5%–100%
1. Age 55+
2. Inability to bear weight for four steps both immediately after the injury and at the time of the exam
3. Inability to flex the knee to 90°
4. Tenderness over the head of the fibula or isolated tenderness to the patella without other bony tenderness.
300
A 70-year-old female who is an established patient at your practice calls you late on a Saturday afternoon. Earlier in the day she misjudged the location of a bench at a neighbor’s house and sat down hard on the porch floor. She felt immediate pain in her back. She went home and took naproxen, 440 mg, and sustained-release acetaminophen, 1300 mg, 3 hours ago. She still describes her pain as unbearable, rating it as 10 on a scale of 10. You agree to meet her in the emergency department, where you confirm an acute T12 vertebral compression fracture.
Of the following, the most appropriate treatment option for this patient’s acute pain is a short course of
A) prescription-strength NSAIDs
B) methadone
C) transdermal fentanyl
D) immediate-release oxycodone (Roxicodone)
D) immediate release oxycodone (Roxicodone)
The most appropriate treatment for this patient’s acute pain following a T12 vertebral compression fracture is round-the-clock class II narcotics.
NSAIDs and acetaminophen are usually insufficient during the acute phase
Methadone or transdermal fentanyl can be used, but plasma levels of methadone may take 5–7 days to stabilize and fentanyl takes 24–48 hours to take effect.
300
Which one of the following interventions has the best evidence for effectiveness in the treatment of frailty syndrome in geriatric patients?
A) Protein supplements
B) Vitamin D supplements
C) Hormonal treatment with anabolic steroids
D) Aerobic conditioning training
E) Progressive resistance training
E) Progressive resistance training
In geriatric patients with frailty syndrome, the intervention with the best evidence for effectiveness is progressive resistance training as a part of a physical activity program.
Aerobic conditioning training may be helpful but the strongest evidence for efficacy is for activities that include progressive resistance training.
400
A 72-year-old female presents with progressive hand pain and stiffness. She is a seamstress and is concerned because sewing has been more difficult over the past 6 months. She recalls that her mother’s hands were misshapen, but her mother never received a diagnosis. You examine her hands, which are shown below.
Which one of the following would be the most appropriate pharmacotherapy?
A) Colchicine (Colcrys)
B) Diclofenac (Zorvolex)
C) Hydroxychloroquine (Plaquenil)
D) Infliximab (Remicade) injections
E) Methotrexate (Trexall)
B) Diclofenac (Zorvolex)
Colchicine and methotrexate have not been studied for the treatment of osteoarthritis
Conventional synthetic and biologic disease-modifying medications such as hydroxychloroquine and infliximab have not been shown to be effective in the treatment of osteoarthritis.
400
Which one of the following disorders is caused by an underlying mechanism of osteochondrosis rather than apophysitis?
A) Legg-Calvé-Perthes disease
B) Osgood-Schlatter disease
C) Sever’s disease
D) Sinding-Larsen-Johansson syndrome
A) Legg-Calve-Perthes disease
Osteochondrosis: degenerative changes in the epiphyseal ossification areas of growing bones.
Apophysitis: traction injury to the cartilage and bony attachments of tendons in growing children.
Legg-Calvé-Perthes disease is a type of osteochondrosis that affects the femoral head. Refer to an orthopedist and instruct to avoid all weight-bearing activities until reossification occurs
Osgood-Schlatter, Sever's disease, and Sinding-Larsen Johansson syndrome are all apophysitis disorders affecting the anterior tibial tubercle, posterior heel, and inferior patellar pole respectively
400
According to the Ottawa knee rule, which one of the following factors may warrant radiography in a patient with an acute knee injury?
A) Age <30
B) Injury from a fall or blunt trauma
C) A twisting mechanism of injury
D) Inability to flex the knee to 90°
E) The presence of a joint effusion within 24 hours of the injury
D) Inability to flex the knee to 90°
The major criteria of the Ottawa knee rule are:
1. age 55+
2. inability to bear weight for four steps both immediately after the injury and at the time of the examination
3. inability to flex the knee to 90°
4. tenderness over the head of the fibula
5. isolated tenderness to the patella without other bony tenderness
400
An 11-year-old female is brought to your office by her parent who is concerned that the child’s spine might be curved. The most appropriate evaluation for scoliosis at this point is
A) comparing the length from the pelvic brim to the pelvic floor on the left and the right
B) scoliometer measurement with the patient bent over to 90°
C) scoliometer measurement with the patient upright and arms to her side
D) determination of the Cobb angle with the patient bent over to 90°
E) determination of the Cobb angle with the patient upright and arms to her side
B) scoliometer measurement with patient bent over to 90°
Most appropriate initial test when evaluating for scoliosis. Scoliometer should be used with the patient’s spine parallel to the floor (bent over to approximately 90°), with the arms hanging down, palms together, and feet pointing forward.
Determination of Cobb angle should be done upright and is only used if 5-7° of trunk rotation is assessed by the scoliometer.
400
A 27-year-old male presents to establish care after relocating to the community. He was diagnosed with β-thalassemia major at birth and has been transfusion-dependent since early childhood. His microcytic anemia is stable with blood transfusions every 4 weeks, but his most recent DEXA scan indicates an advancement from osteopenia to osteoporosis.
In addition to bisphosphonates, calcium, and vitamin D, which one of the following medications may improve his bone density?
A) Hydroxyurea (Hydrea)
B) Vitamin C
C) Zinc
D) Deferoxamine (Desferal)
E) Luspatercept (Reblozyl)
C) Zinc
In addition to bisphosphonates, calcium, and vitamin D, zinc supplementation is recommended to improve bone density in patients with thalassemia and osteoporosis (SOR C).
Hydroxyurea does not improve bone density
Vitamin C does not improve bone density
Deferoxamine infusions are indicated to reduce iron load after transfusion but do not improve bone density
500
A 57-year-old female presents for follow-up 6 weeks after falling and breaking her wrist. The fracture has healed but she has developed burning pain in the area of the fracture, which she rates as 9 on a scale of 10. On examination you note moderate hyperalgesia in the area with some minimal localized swelling. You suspect complex regional pain syndrome (CRPS).
CRPS is best diagnosed with which one of the following?
A) The patient history and physical examination
B) Ultrasonography
C) MRI
D) Nerve conduction testing
E) A technetium 99m bone scan
A) Patient history and physical exam
US, MRI, and nerve conduction testing can rule out other diagnoses but are not necessary to diagnose CRPS.
Nerve injury is not always seen with CRPS
Technetium 99m bone scan can reveal resorption at site but is not sensitive or specific for CRPS.
500
A 24-month-old female is brought to your office by her mother because the child will not stand on her right leg. Yesterday the patient was playing at the park and her mother did not notice any injury occur. There has been no recent illness or fever. The child was born at full term, has had no medical problems, and is up to date on vaccinations.
The patient’s vital signs are normal. A physical examination reveals a healthy-appearing child in no apparent distress. She grimaces and pulls away with palpation of the right leg over the lower tibia and she will not bear weight. She has full passive range of motion of her hip, knee, and ankle joints bilaterally without apparent pain. Anteroposterior and lateral radiographs of her right tibia and fibula show no abnormalities.
Which one of the following would be the most appropriate next step in management?
A) Reassurance only
B) A CBC and C-reactive protein level
C) Immobilization with a cam boot, and repeat radiographs in 7 days
D) Bone scintigraphy
E) Referral to an orthopedic surgeon
C) Immobilization with cam boot, repeat radiographs in 7 days
Nondisplaced spiral fracture of the distal tibial shaft (toddler’s fracture) should be suspected in children from 9 months to 3 years of age who present with pain in the distal third of the tibia after minor or even unnoticed injury
Can have subtle radiographic findings and may not be visible on initial radiographs, so repeat radiography to look for healing is appropriate. Standard treatment is immobilization of the affected leg.
No signs of infection (osteomyelitis)
Bone scintigraphy as follow-up if Xray not sensitive enough and symptoms persist
Heal without complication (no ortho consult)
500
According to the Ottawa ankle and foot rules, which one of the following patients with ankle or foot pain after a twisting injury requires radiographs to rule out a fracture?
A) An 18-year-old male basketball player who landed on an opposing player’s foot while rebounding the ball and has tenderness anterior to the lateral malleolus
B) A 23-year-old female who twisted her ankle while playing soccer and has tenderness at the base of the fifth metatarsal
C) A 30-year-old male who twisted his ankle a week ago after stepping on his child’s toy and has persistent swelling with tenderness anterior to the medial malleolus
D) A 48-year-old female who slipped while going down stairs and has tenderness and bruising inferior to the lateral malleolus
B) A 23-year-old female who twisted her ankle while playing soccer and has tenderness at the base of the fifth metatarsal
Ottawa ankle rules has a sensitivity of nearly 100% and a specificity of 30%–40%.
Rules:
Pain in the malleolar zone plus one or more of the following:
1. bony tenderness over the distal 6 cm of the posterior lateral or medial malleolus (the areasof potential fracture)
2. the inability to bear weight for four steps immediately after the injury and at the time of the examination.
500
A 10-year-old female is brought to your office for a sports preparticipation examination. You note thoracic rib asymmetry during the Adams forward bend test. Radiographs confirm rightward thoracolumbar scoliosis with a Cobb angle of 32°.
Which one of the following would be most appropriate at this time?
A) Genetic testing (ScoliScore)
B) MRI of the thoracic and lumbar spine without contrast
C) Scoliosis radiography in 1 year
D) Referral to physical therapy
E) Referral to a pediatric orthopedist
E) Referral to a pediatric orthopedist
Patient is a skeletally immature female with a Cobb angle that puts her at increased risk for progression (>29°). Referral to a spine specialist for consideration of bracing and appropriate follow-up is recommended.
Genetic testing is available to help determine the risk of progression, but it is not a widely validated tool at this time.
MRI does not provide any additional information to help with decision-making.
Because of the patient’s increased risk of progression, simple follow-up in 1 year is not recommended.
Physical therapy is not indicated for the primary treatment of scoliosis.
500
A 45-year-old male sees you for a routine visit. His medical history includes hypertension treated with hydrochlorothiazide, amlodipine (Norvasc), and losartan (Cozaar). He also has type 2 diabetes treated with metformin and empagliflozin (Jardiance). Laboratory findings are significant for an LDL-cholesterol level of 167 mg/dL and you prescribe simvastatin (Zocor), 80 mg daily. At a follow-up visit 3 months later he tells you that he stopped taking the simvastatin after a week due to muscle pain and weakness.
Which one of the following medications in this patient’s current regimen most likely contributed to his risk for developing statin-induced myopathy?
A) Amlodipine
B) Empagliflozin
C) Hydrochlorothiazide
D) Losartan
E) Metformin
A) Amlodipine
Most statins are metabolized in the liver by cytochrome P450 3A4 (CYP3A4) enzymes. Concurrent use of other medications also metabolized by this system, including amiodarone, CCBs (amlodipine), certain anti-HIV medications, and certain antifungal medications, can increase the risk of complications such as statin-induced myopathy.
In this patient, only simvastatin and amlodipine are metabolized by CYP3A4. Losartan is metabolized by cytochrome P450 enzymes other than 3A4 (2C9).